Percentage of Patients With Pressure Ulcers/Pressure Injuries That Are New or Worsened

Identifying Attributes

Care Settings
Rehabilitation Care
Country
United States of America
Publishing Organisation
Centers for Medicare & Medicaid Services (CMS): Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP)
Type of Quality Indicator
Outcome
IOM Quality Dimension
Person-Centredness
Domain
Adverse Events

Defining Attributes

Definition

Percentage of patients with pressure ulcers/pressure injuries that are new or worsened.

Numerator

The numerator is the total number of IRF stays for which the IRF-PAI indicates one or more new or worsened Stage 2-4 pressure ulcer(s) or unstageable pressure ulcers due to slough/eschar, non-removable dressing/device, or deep tissue injury at discharge, compared to admission. 1) Stage 2 (M0300B1) - (M0300B2) > 0, OR 2) Stage 3 (M0300C1) - (M0300C2) > 0, OR 3) Stage 4 (M0300D1) - (M0300D2) > 0, OR 4) Unstageable – Non-removable dressing/device (M0300E1) - (M0300E2) > 0,OR 5) Unstageable – Slough and/or eschar (M0300F1) - (M0300F2) > 0,OR 6) Unstageable – Deep tissue injury (M0300G1) - (M0300G2) > 0.

Denominator

The total number of IRF stays with discharge date in the measure target period, which do not meet the exclusion criteria.

Exclusions

An IRF stay is excluded if: Data on new or worsened Stage 2, 3, 4, and unstageable pressure ulcers/injuries are missing at discharge: • (M0300B1 = [-] or M0300B2 = [-]) and (M0300C1 = [-] or M0300C2 = [-]) and (M0300D1= [-] or (M0300D2= [-]) and (M0300E1= [-] or M0300E2 = [-]) and (M0300F1= [-] or M0300F2 = [-]) and (M0300G1= [-] orM0300G2=[-]) The patient died during the IRF stay: • Item 44C = [0]

Use of Risk Adjustment
Yes
Risk Adjustments

Data for each covariate are derived from the IRF-PAI admission assessment data included in the target IRF stays. 1. Functional Mobility Admission Performance: Coding of dependent or substantial/maximal assistance for the functional mobility item Lying to Sitting on Side of Bed at admission: a. Covariate = [1] (yes) if GG0170C = [01, 02, 07, 09, 10, 88] ([01] = Dependent, [02] =Substantial/maximal assistance, [07] = Patient refused, [09] = Not applicable, [10] = Not attempted due to environmental limitations, [88] = Not attempted due to medical condition or safety concerns) b. Covariate = [0] (no) if GG0170C = [03, 04, 05, 06, -] ([03] =Partial/moderate assistance, [04] =Supervision or touching assistance, [05] =Setup or clean-up assistance, [06] = Independent, [-] =No response available) 2. Bowel Incontinence: Bowel Continence (H0400) at admission a. Covariate = [1] (yes) if H0400 = [1, 2, 3] ([1] = Occasionally incontinent, [2] = Frequently incontinent, [3] = Always incontinent) b. Covariate = [0] (no) if H0400 = [0, 9, -] ([0] = Always continent, [9] = Not rated, [-] = Not assessed/no information) 3. Peripheral Vascular Disease / Peripheral Arterial Disease or Diabetes Mellitus: a. Covariate = [1] (yes) if any of the following are true: i. I0900 = [1] (checked) ii. I2900 = [1] (checked) b. Covariate = [0] (no) if I0900 = [0, -] AND I2900 = [0, -] ([0] = No, [-] = No response available) 4. Low body mass index (BMI), based on height (25A) and weight(26A): a. Covariate = [1] (yes) if BMI ≥ [12.0] AND ≤ [19.0] b. Covariate = [0] (no) if BMI < [12.0] OR BMI > [19.0] c. Covariate = [0] (no) if Item 25A = [0, 00, -] OR Item26A = [-] ([-] = No response available) Where: BMI = (weight * 703 / height2) = ([Item 26A] * 703) / (Item 25A2) and the resulting value is rounded to one decimal place.* *To round off the percent value to one decimal place, if the digit in the second decimal place is greater than 5, add 1 to the digit in the first decimal place; otherwise, leave the digit in the first decimal place unchanged. Drop all the digits following the digit in the first decimal place.

Stratifications

Data Attributes

Type of Data Collection
Standardised clinical data
Data Collection Methods

Effective on October 1, 2022, the IRF-PAI Version 4.0 is used to collect and submit assessment data for the IRF QRP.

Frequency of Data Collection
Quarterly
Frequency of Data Collection in Days
91
Reporting Methods

Internet Quality Improvement and Evaluation System (iQIES).

Reporting Frequency
Quarterly
Reporting Frequency in Days
91
Indicator Has Recommended Targets
No

Source and Reference Attributes

Evidence Source

Centers for Medicare & Medicaid Services (CMS), United States. Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Measures Information. Accessed August 3, 2023. Available from: www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/irf-quality-reporting/irf-quality-reporting-program-measures-information-.

Centers for Medicare & Medicaid Services (CMS), United States. Inpatient Rehabilitation Facility Quality Reporting Program Measure Calculations and Reporting User’s Manual. Accessed August 3, 2023. Available from: www.cms.gov/files/document/irf-quality-measure-calculations-and-reporting-users-manual-v40.pdf.

Centers for Medicare & Medicaid Services (CMS), United States. Inpatient rehabilitation facilities - The Measures. Accessed August 3, 2023. Available from: data.cms.gov/provider-data/topics/inpatient-rehabilitation-facilities/measures.

Link to Measurement Tools

Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI)

Quality Indicator Confirmed to be Part of a Program Used to Monitor Quality and Safety of Care Among Older People at a Population-Level between 2012-2022
Yes
Assessed by the Australian Consortium for Aged Care Collaborators as Generally Containing Good Properties (Importance and Scientific Acceptability)
No
Australian Consortium for Aged Care Endorsed
No
Identified by PHARMA-Care Project
No
Upload Date
12 March 2025